Clinical assessment of alcohol intoxication
| Clinical signs | Severity/prominence | |||||||
|---|---|---|---|---|---|---|---|---|
| Very severe | Severe | Moderate | Mild | None | Not applicable (specify) | |||
| Smell of alcohol on breath | ||||||||
| Conjunctival injection and/or flushed face | ||||||||
| Impairment of speech—for example, slurring | ||||||||
| Impairment of motor coordination | ||||||||
| Impairment of attention and/or judgement | ||||||||
| Elated (euphoria) or depressed mood | ||||||||
| Disturbances in behavioural responses | ||||||||
| Disturbances in emotional responses | ||||||||
| Impaired ability to cooperate | ||||||||
| Horizontal gaze nystagmus | ||||||||
| Y91 | Based on the signs above, would you say that the patient is in the state of: (Tick appropriate box) | |||||||
| Y91.3 | Very severe alcohol intoxication (Very severe disturbance in functions and responses, very severe difficulty in coordination, or loss of ability to cooperate) | |||||||
| Y91.2 | Severe alcohol intoxication (Severe disturbance in functions and responses, severe difficulty in coordination, or impaired ability to cooperate) | |||||||
| Y91.1 | Moderate alcohol intoxication | |||||||
| (Smell of alcohol on breath, moderate behavioural disturbance in functions and responses, or moderate difficulty in coordination) | ||||||||
| Y91.0 | Mild alcohol intoxication (Smell of alcohol on breath, slight behavioural disturbance in functions and responses, or slight difficulty in coordination) | |||||||
| Y91.9 | Alcohol involvement, not otherwise specified Please specify reason: Not intoxicated at all | |||||||
| Do you think that there is any evidence of substance usage other than alcohol? | ||||||||
| No | ||||||||
| Yes, based on self report | ||||||||
| Yes, based on collateral information | ||||||||
| Yes, based on self report and collateral information | ||||||||
| Not sure | ||||||||